When we schedule new patient appointment, this is one full hour blocked just for you. Unfortunately, due to the large number of No Shows at first appointment, we now request $100 deposit at the time of booking new patient appointment. Deposit is fully refundable, if you keep your appointment, or cancel giving us at least 48 hrs notice.
You can call the office with payment information, or you can use credit card authorization form and fax it back to us at 813 464 7682.
Please print, fill out and bring these form with you to your first appointment with the doctor. If you are not able to print them, please arrive at least twenty minutes before your scheduled appointment time.
Please make sure to download the forms to your computer before filling them out. If you enter information from this page into the form, it won't be saved. All signature must be either signed by hand, or digitally signed. Typying in the patient name is not a valid signature.
→ New Patient Forms - Psychiatry
→ New Patient Forms - Counseling
If the patient is a minor, please bring also these forms:
→ Vanderbilt ADHD Parent Questionnaire
→ Vanderbilt ADHD Teacher Questionnaire
→ Authorization for release of confidential information
→ Credit Card Authorization Form
→ Office Policy
Why should you check your mental health benefits BEFORE the first appointment?
Mental Health Benefits often have different set of rules than your other medical benefits:
- Your co-pay, co-insurance, or deductible requirements might differ.
- You might require a precertification (authorization) for mental health specialist.
- You might require a refferal from your PCP.
- There might be a limit on the number of allowed office visits.
- There might be restrictions on length and type of your appointments.
- There might be a limit on the $ amount allowed for mental health per year.
- There could be some other restrictions, not mentioned above.
You may also fax us the copy of your insurance card (front and back) and patients DOB, and we will check the benefits for you.
Fax: 813-464-7682 (both locations)